TSB Financial Assistance Program Application

APPLICATIONTARGETED SMALL BUSINESS

FINANCIAL ASSISTANCE PROGRAM

The Iowa Department of Economic Development provides loans or grants up to a maximum of $50,000 to Iowa businesses that are at least 51% owned and actively managed by minorities and/or women or persons with disabilities. THE BUSINESS MUST BE CERTIFIED AS A "TARGETED SMALL BUSINESS" BY THE STATE OF IOWA, BEFORE APPLYING FOR OR RECEIVING FUNDS UNDER THIS PROGRAM.

INSTRUCTIONS:

1. Fill out application materials completely. If any questions are left unanswered or required attachments are not submitted, an explanation for the omission must be included. Only complete applications will be considered for funding.

2. Applications must either be typed or handwritten in ink. The original application must be submitted on this form to the Department of Economic Development.

3. Applications will be reviewed and evaluated on criteria such as: budget factors, business design, demonstrated need of applicant, feasibility of plan, credit worthiness, previous business experience, etc.

4. The Iowa Department of Economic Development reserves the right to request addi-tional information for the purpose of determining eligibility and assessing this application.

5. As a part of this application, the Department of Economic Development requires two years of projected cash flow statements, profit and loss statements, and balance sheets (forms are attached). If the business applicant is an existing firm, we also require the most current three years' balance sheet and profit and loss statement and schedule C's from your federal income taxes or some other reasonable statement of business condition.

Generally, funds provided under the TSBFAP program will be in the form of low interest loans. However, if a business can show that a grant is necessary to leverage either SBA or conventional bank financing, a grant may be considered. Grant funds may be considered taxable income by the Internal Revenue Service and the Iowa Department of Revenue and Finance; therefore, a 1099 form may be issued.

There are three major parts to the attached application (Personal Information, Personal Financial Information, Business Proposal). Each section must be filled out completely in order to be considered for funds. Applicants must submit six-month balance sheet and income statements and tax returns if existing business. No application will be funded 100% by TSB funds and the business owner must also inject cash in an amount that is at least 10% of the total project costs.

Applicants must score a minimum of 60 out of a possible 100 points in order to be recommended for funding. Points are awarded based on the information contained in the application according to the following criteria:

15/25/2007

Business Plan (20 points possible) - Does the application contain significant information regarding the product or service to be offered? Has the applicant provided sufficient documentation to support/justify the cash flow assumptions, e.g. third-party documentation regarding market size, annual sales and competition?

Financial Plan (20 points possible) - Does the application contain comprehensive two-year cash flow projections which show the viability of the business? Does the application provide completed personal financial information and information on other funding sources?

Financial Need (20 points possible) - The applicant's personal liquid assets and their ability or inability to secure a loan from conventional sources (i.e. bank, savings and loan, credit union, SBA).

Market Plan (5 points possible) - Does the application contain sufficient information to ascertain that the applicant fully understands who the customers are and how to effectively reach them?

Management Expertise (20 points possible). Does the applicant have education or work experience that is relevant to the proposed business? Does the application document previous business training or management experience?

Loan Repayment (10 points possible) - Does the application document the business' ability to service its debt?

Nontraditional (5 points possible) - Is the proposed business category one in which TSBs have traditionally been under-represented as owners?

The appendix included at the back of this application lists the Small Business Development Centers located throughout Iowa. These centers can provide a wide range of assistance to small business operators or entrepreneurs. Each of the centers has staff trained to assist clients in the preparation of business plans, cash flow statements, and profit and loss statements. Please contact the center nearest you for help in completing the forms required for this application.

Questions concerning the program as well as submission of applications should be directed to:

Donna LoweryTargeted Small BusinessIowa Department of Economic Development200 East Grand AvenueDes Moines, IA 50309Telephone: 515/242-4813

Questions concerning certification, as well as submission of application for certification, should be directed to:

Mary T. MontgomeryTargeted Small Business CertificationDepartment of Inspections and AppealsLucas State Office Building321 East 12th StreetDes Moines, IA 50319Telephone: 515/281-5796

25/25/2007

PERSONAL INFORMATION

Name:______________________________________________Social Security No:___________________

Address:________________________________ City:__________________________________________

County:_________________________________ Zip Code:______________________________________

Telephone:( )__________________________ (or where message can be left ( )___________

Are you a resident of Iowa?_____________________


Address:________________________________ City:__________________________________________

County:________________________________ Zip Code:______________________________________




Address:________________________________ City:__________________________________________

County:________________________________ Zip Code:______________________________________



Business Name:_____________________________________Federal I.D. No:______________________

Mailing Address:_________________________________________________________________________

Street Address:__________________________________________________________________________

Years in Business: ________ Current Number of Employees: Part Time: _____ Full Time: _____

Business Contact Person:___________________________________ Phone Number: ( )________

35/25/2007

BACKGROUND

Please list any education, training, or work experience that is related to your proposed business:

1. EDUCATION

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. TRAINING:

3. WORK EXPERIENCE (3 - 5 years)

Did you have assistance in the preparation of this application? Yes_____ No _____

If yes, Name, Address and Phone:_________________________________________________________

_________________________________________________________

_________________________________________________________

Do you wish them to be notified when a decision has been reached? Yes______ No______

If funds are awarded, do you wish for them to receive any correspondence sent to you throughout the period of the loan? Yes______ No ______

Does the project include the initial construction of any building or facility?Yes _____ No _____If yes, does the local jurisdiction have a local building code in place which it enforces through a system of plan reviews and inspections? Yes _____ No _____

45/25/2007

PERSONAL FINANCIAL STATEMENT

A. List all current assets and liabilities. (MUST BE COMPLETED.)

Current Personal AssetsCash/Checking Account (Bank_____________________________________) $_____________________

Savings Account(s) (Bank_____________________________________) $_____________________

Stocks/Bonds/Securities $_____________________

Accounts/Notes Receivable $_____________________

Autos/Other Vehicles (Model & Yr. _____________________) $ ____________________

Real Estate Value $ ____________________

Other Assets: (list) ___________________________ $ ____________________ ___________________________ $ ____________________ ___________________________ $ ____________________

Total Assets: $ _____________________________________________________

Current Personal LiabilitiesBalance on Car $ ____________________ (Holder of 1st lien_________________________________)

Balance on home $ ____________________ (Bank ______________________________________________)

Credit Card liability (Company _______________________) $ ____________________

Other loans (list)____________________________________) $ ____________________ Other liabilities: (List creditor and amount.)

Child Support $_____________________

State Tax Liability (Personal or Business) $_____________________

Federal Tax Liability (Personal or Business) $_____________________

______________________________________________________

Total Liabilities: $ ___________________________________________________

Total Assets $ _____________________________

Less Total Liabilities $ _____________________________ = Net Worth $ ____________________

_______________________________

IIIBUSINESS PROPOSAL

A. Please provide a brief description of your project proposal. (Please limit your response to the space provided.)

B. Project Budget Proposal

List of Project Costs (Use of Funds) Amount

Purchase Real Estate & Closing Costs $_____________________________

Remodeling Costs $_____________________________

Machinery and Equipment $_____________________________

Furniture and Fixtures $_____________________________

Supplies $_____________________________

Inventory $_____________________________

Other $_____________________________

Start Up Costs

Advertising $________________________

Rental Deposit $________________________

Utilities Deposits $________________________

Insurance $________________________

Professional Fees $________________________

Licenses & Permits $________________________

Other (__________) $________________________

Total $_____________________________

Working Capital $_____________________________

TOTAL PROJECT COSTS $_____________________________

Sources of Funds for Project

Business Owner's Cash Contribution $_____________________________

Bank Loan(s) $_____________________________

Other (___________________) $_____________________________

Other (___________________) $_____________________________

State Financial Assistance Needed $_____________________________

TOTAL SOURCES: $_____________________________

(Should equal total project costs)

Type of State Assistance Requested

Loan $_____________________________

Equity Grant $_____________________________

UP TO $50,000 IS THE MAXIMUM AVAILABLE. (GRANT FUNDS MAY BE CONSIDERED TAXABLE INCOME BY THE INTERNAL REVENUE SERVICE AND THE IOWA DEPARTMENT OF REVENUE AND FINANCE; THEREFORE, A 1099 FORM MAY BE ISSUED.) (For loans, please specify desired rate of interest _______% term _______yrs, and

other special conditions requested.

C. Is the applicant business at least 51% owned and actively managed by minorities, women and/or persons with disabilities? ______YES _______NO

Is the applicant certified as a Targeted Small Business by the State of Iowa? ________YES _______NO

D. If a loan is being requested, list security for the loan (co-signer, property, product, etc.). Be specific, including model numbers and serial numbers if applicable.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. List of three character references: (previous employer, local business person,landlord, etc.)

1._______________________________________________ Phone Number: ( )_______________

Relationship to Applicant:_________________________________________________________

2._______________________________________________ Phone Number: ( )_______________


3._______________________________________________ Phone Number: ( )_______________


F. Are you able to travel to Des Moines for an interview: ______YES ______NO(Your response to this question will have no influence on the Department's decision to award you a loan.)

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

ApplicantSignature: _______________________________________________ Date:________________________

A person who engages in deception and knowingly makes or causes to be made, directly or indirectly, a false statement in writing, for the purpose of procuring economic development assistance from a state agency or political subdivision, for the benefit of the person or for whom the person is acting, is guilty of a fraudulent practice in the first degree as defined in Section 714.9.

A Class "C" Felon, not a habitual offender, shall be confined for no more than ten years,

and in addition may be sentenced to a fine of not more than $10,000.

I. DESCRIPTION OF THE BUSINESS

A. Explain your current (or proposed) business.

B. Indicate what type of business.1. Wholesale 4. Manufacturing2. Retail 5. Construction3. Service 6. Other, (explain) _______________

C. Business Status1. Start-up2. Existing3. Take-over of Existing

D. When will (did) your business open?

E. Business Form1. Sole Proprietorship 3. Subchapter S2. Partnership 4. Corporation

F. If Partnership, Subchapter S, or Corporation, have formal arrangements beenmade?

If not, when will they be completed?

G. What type of experience do you have in this business?

H. What are normal or proposed business hours?

II. FOR A NEW/EXPANDING BUSINESS

A. What will be special or unique about your business? Will you offer a new product or service?

B. Have you spoken to others in this kind of business? What was their response?

C. Have you spoken with vendors/suppliers to find out what managerial and/or technical help they will provide? If so, who are they and what will they provide.

D. Have you asked about vendor credits? Has credit been granted? If granted, What are the terms?

E. If you will be doing contract work, have you developed the terms? If so, what are they? Reference any firm contract and include it as a supporting document.

III. FOR A BUSINESS TAKEOVER

A. When and by whom was the business founded?

B. Why is the owner selling?

C. What was the purchase price of the business? How was that price determined?

D. What is the trend of sales? (Upward? Downward? Stable?) If downward, pleaseexplain.

IV. THE MARKET

A. Who will be your targeted customers?

B. Where are your customers located? Why does your area need a new business like yours?

C. What is the present size of your market?

D. How are you going to satisfy your market?

E. What kinds of promotion will you use in your marketing efforts? How much will you be spending on promotion (fixed dollar figure or percent of sales)?

F. How have you determined the selling price for your product or service? What is your price? Include as a supporting document if necessary.

G. How much will you sell in a day, a week, a month in dollars? Will your business have seasonal sales? If so, what will be the high sales amounts and the low sales amounts?

H. What special advantages does your product or service offer that might justify higher prices?

I. Will you be offering credit terms to your customers? If so, what will they be?

V. COMPETITION

A. Who are your five nearest competitors? List by name and location.

1.2.3.4.5.

B. Describe your competition.

Is their business increasing, decreasing or stable?

What are their competitive strengths and weaknesses?

How will your business differ from theirs?

If you have been in a position to observe your competitors operations, what haveyou learned?

C. How will your business be better than your competitor's?

VI. LOCATION

A. In what type of area is your business located (i.e. home, downtown, rural, etc.)

B. Is the building owned or leased? State the terms. (Provide supporting documentation.)

If renovations are necessary, what are they? Get quotes in writing from more than one contractor. Include quotes as supporting documents. Provide a complete list of renovation expenses.

C. What types of special permits or licenses will you need to operate yourbusiness?

D. Do local zoning ordinances permit your type of business in the proposed (actual)location? If not, what are you doing to correct the situation.

E. Describe the physical characteristics of your building.

F. What made you choose this location for your business?

VII. PERSONNEL

A. What are your current employee needs? In one year? In two years?

B. What skills must they have?

C. Are the people you need available?

D. Will you have full-time or part-time employees?

E. How will they be compensated? (salary or hourly rate?)

F. Will you provide fringe benefits to employees?

G. Will you be required to train employees? Explain time and cost commitments ofthe business to training activities.

VIII. GENERAL CONSIDERATIONS

A. What kinds of insurance needs does your business have?

Have they been secured? Who is your agent(s)?

IX. GENERAL SUMMARY

A. List at least five factors that are critical to the success of your business.

B. Client statement. Use this section to clarify any questions about your business that the loan processor may have that have not been included in the general plan.

PROJECTED BALANCE SHEET

Year One

ASSETS AMOUNT

Current Assets

Cash On Hand $___________________________

Accounts Receivable $___________________________

Inventory $___________________________

Prepaid Expenses $___________________________

Other $___________________________

TOTAL CURRENT ASSETS $___________________________

Fixed Assets

Equipment $___________________________

Land and Building $___________________________

Less Depreciation (__________________________)

NET FIXED ASSETS $___________________________

TOTAL ASSETS $ __________________________

LIABILITIES

Current Liabilities

Accounts Payable $___________________________

Notes Payable - Bank $___________________________

Current Portion LTD $___________________________

TOTAL CURRENT LIABILITIES $___________________________

Long Term Debt $___________________________

Officer's Debt $___________________________

TOTAL LIABILITIES $___________________________

Common Stock $___________________________

Paid in Capital $___________________________

Retained Earnings $___________________________

(Less) Treasury Stock $___________________________

TOTAL NET WORTH $___________________________

TOTAL LIABILITIES AND NET WORTH $ __________________________

PROJECTED BALANCE SHEET

Year Two

ASSETS AMOUNT

Current Assets

Cash On Hand $___________________________

Accounts Receivable $___________________________

Inventory $___________________________

Prepaid Expenses $___________________________

Other $___________________________

TOTAL CURRENT ASSETS $___________________________

Fixed Assets

Equipment $___________________________

Land and Building $___________________________

Less Depreciation (__________________________)

NET FIXED ASSETS $___________________________

TOTAL ASSETS $ _________________________

LIABILITIES

Current Liabilities

Accounts Payable $___________________________

Notes Payable - Bank $___________________________

Current Portion LTD $___________________________

Other Current Liabilities $___________________________

TOTAL CURRENT LIABILITIES $___________________________

Long Term Debt $___________________________

Officer's Debt $___________________________

TOTAL LIABILITIES $___________________________

Common Stock $___________________________

Paid in Capital $___________________________

Retained Earnings $___________________________

(Less) Treasury Stock $___________________________

TOTAL NET WORTH $___________________________

TOTAL LIABILITIES AND NET WORTH $ __________________________

PROJECTED PROFIT AND LOSS STATEMENT

Year One

ANNUAL

Sales $__________________________

Less: Cost of Goods Sold $__________________________

Gross Profit $__________________________

Operating Expenses

Payroll (excluding owner's draw) $__________________________

Payroll Taxes $__________________________

Advertising $__________________________

Car, Deliver, Travel $__________________________

Depreciation $__________________________

Dues and Subscriptions $__________________________

Insurance $__________________________

Laundry $__________________________

Licenses and Business Taxes $__________________________

Maintenance and Repairs $__________________________

Professional Fees $__________________________

Rent $__________________________

Supplies $__________________________

Telephone $__________________________

Utilities $__________________________

Miscellaneous Expense $__________________________

Total Operating Expenses $__________________________

Profit or (Loss) $ __________________________

PROJECTED PROFIT AND LOSS STATEMENT

Year Two

ANNUAL

Sales $__________________________

Less: Cost of Goods Sold $__________________________

Gross Profit $__________________________

Operating Expenses

Payroll (excluding owner's draw) $__________________________

Payroll Taxes $__________________________

Advertising $__________________________

Car, Deliver, Travel $__________________________

Depreciation $__________________________

Dues and Subscriptions $__________________________

Insurance $__________________________

Laundry $__________________________

Licenses and Business Taxes $__________________________

Maintenance and Repairs $__________________________

Professional Fees $__________________________

Rent $__________________________

Supplies $__________________________

Telephone $__________________________

Utilities $__________________________

Miscellaneous Expense $__________________________

Total Operating Expenses $__________________________

Profit or (Loss) $ ________________________

DEPARTMENT OF ECONOMIC DEVELOPMENTDISCLOSURE OF INFORMATION

NOTICE TO APPLICANT

Disclosure of information requested by the Department of Economic Development is voluntary. However, failure to disclose certain items of information requested may result in a delay in the processing of an application or its rejection.

The primary purposes for collecting the requested information are to determine eligibility for a loan under the Targeted Small Business Finance Program (TSBFAP), to assess the creditworthiness of the applicant, to develop the most appropriate loan terms, and to provide statistical analysis. Information provided may be used outside of the Department of Economic Development for the following purposes:

1. Release to interested parties who submit requests for information under Iowa Code Chapter 22, Examination of Public Records.

2. To provide the basis for borrower success stories inDepartment of Economic Development news releases.

3. Referral to employers, businesses, landlords, creditorsor others to determine repayment ability.

4. Referral to a credit reporting agency.

5. Referral to a person or organization when the Departmentdecides the referral is appropriate to assist in thecollection or servicing of the loan.

6. Referral to the State Records Management facility for storage.

Efforts will be made to protect the privacy of applicants and borrowers to the extent possible consistent with State law.

Unless treated as confidential under State law, all information supplied to the Department of Economic Development by you or your agents in connection with your loan application may be released to interested third parties, including competitors, without your knowledge or consent under the provisions of Chapter 22, Examination of Public Records. Information submitted may be made available to the public during the time it is held in Department files regardless of the action taken by the Department on your application.

My signature acknowledges that I have read the above, accept the conditions stated therein and have received a copy of the above Notice to Applicant regarding disclosure of information.

____________________________________ _________________________Signature Date

_____________________________________________________________________________

DEPARTMENT OF ECONOMIC DEVELOPMENTAUTHORITY FOR RELEASE OF INFORMATION AND RECORDS

________________________________________________________________________________

I have been provided with a copy of a statement advising me that certain information is required to assist the Department of Economic Development in making a determination concerning my loan application under the Department's Targeted Small Business Financial Assistance program (TSBFAP) and that execution of this form is voluntary.

I hereby authorize and consent to the release of information and records bearing on my personal history; personal and business income; bank accounts; credit history; personal and business assets and liabilities; job performance; and arrests and convictions, if any, to representatives of the Department of Economic Development. The information will be used for the purpose of determining my eligibility for assistance under the TSBFP program.

This authorization is valid for the length of the contract with the Iowa Department of Economic Development after my signing. Upon request, a copy of this signed statement may be furnished to a present or former employer, present or former landlord, financial institution, creditor, state or federal agency, criminal justice agency, or other person furnishing information or record.

_____________________________________________________________________________

___

DATE (Year,Mo,Day) NAME (Last,First,MI) SIGNATURE

_____________________________________________________________________________

__

Subscribed and sworn to before me this ________ day of _______________________.

SEAL ____________________________________ Notary